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Private Lesson Application Form - Credit Card Payment

Thank you for taking private lessons at Plugged In and for completing this short application form.

Questions marked with a red asterisk are required and must be answered before submitting your application.

Plugged In is excited to have you participate in our private lesson program!

Student Information
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First Name
Last Name
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mm/dd/yyyy
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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Parent Contact Information
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First Name
Last Name
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Emergency Contact Information
If the student's parents are unreachable during an emergency whom should we contact?
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First Name
Last Name
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Provide the most reliable number for this emergency contact

Ex: student excels in structured environment, student requires breaks, student is shy, etc.
Policy

To participate in Plugged In you must read, understand, and agree to the following policies.  If you have questions regarding any of the following policies please contact Plugged In directly.

Read Release of Liability / Indemnity / Emergency Treatment Agreement

Read Code of Conduct Agreement

 

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